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Instability and bone loss. pptx

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Instability and bone loss. pptx

  1. 1. www.shoulder.gr Shoulder dislocation With Bone Defects Manos Antonogiannakis Orthopaedic Surgeon Director of 3rd Orthopaedic Department Centre for Arthroscopy & Shoulder Surgery Hygeia General Hospital 7th Balkan Congress of Arthroscopy, Sports, Traumatology & Knee Surgery Thessaloniki 2016 .
  2. 2. www.shoulder.gr Shoulder dislocation With Bone Defects Disclosures Zimmer Biomet SportsMed course - Invited Speaker 7th Balkan Congress of Arthroscopy, Sports, Traumatology & Knee Surgery Thessaloniki 2016 .
  3. 3. www.shoulder.gr The Shoulder  Greatest Range of Motion in the Body  Prone to instability Sacrifices stability for mobility
  4. 4. www.shoulder.gr Types of instability Not a black or white issue
  5. 5. www.shoulder.gr Contributors to stability Static stabilizers 1. ligamentous structures labrum and capsule 2. bony configuration of glenoid and humeral head Dynamic stabilizers 1. rotator cuff 2. scapula muscles
  6. 6. www.shoulder.gr Bone Defects  Glenoid side  Humeral side
  7. 7. www.shoulder.gr Glenoid Bone Defects
  8. 8. www.shoulder.gr The inferior 2/3 of the glenoid is nearly a perfect circle with avg diameter 24mm Huysman et al. JSES 2006
  9. 9. www.shoulder.gr Normal Glenoid inverted pear Bony Bankart pear Compression Bankart loss of anterior rim
  10. 10. www.shoulder.gr Traumatic Glenohumeral Bone Defects and Their Relationship to Failure of Arthroscopic Bankart Repairs: Significance of the Inverted-Pear Glenoid and the Humeral Engaging Hill-Sachs Lesion S.S. Burkhart and J. F. De Beer, M.D. Arthroscopy,October 2000
  11. 11. www.shoulder.gr  Total group: 194 patients  173 pt without significant bone defects : 7 pt sustained a recurrence (4%)  21 pt with significant bone defects: 14 pt developed rec instability (67%)
  12. 12. www.shoulder.gr Loss of 8.6mm of anterior radius of glenoid at the level of the bare spot corresponds to 35% of the normal anteroposterior width Lo, Burkhart Arthroscopy 2004
  13. 13. www.shoulder.gr >25 – 30% bone loss 6.5 – 8.6mm AP width Inverted pear appearance Bone block procedures Piasecki et al. AAOS J17 (8): 482. (2009)
  14. 14. www.shoulder.gr  Taverna et al. Pico Method 2D CT – measurement of glenoid surface Critical Limit 25% loss of glenoid surface
  15. 15. www.shoulder.gr  Our practice The percentage of the glenoid defect was evaluated on the en face reconstructed view with the humeral head eliminated Sugaya et al (2005) Joint Surg Am
  16. 16. www.shoulder.gr Glenoid Bone Loss >25% open Latarjet Arthroscopic Latarjet procedure L. Lafosse Arthroscopic Bristow procedure P.Boilleau Arthroscopic shoulder stabilization with a bone block E. Taverna
  17. 17. www.shoulder.gr Humeral Bone Defects Hill-Sachs lesion
  18. 18. www.shoulder.gr Humeral Bone Defects Engaging Non Engaging
  19. 19. www.shoulder.gr Engaging Hill Sachs
  20. 20. www.shoulder.gr Hill- Sachs Remplisage: An arthroscopic surgical solution for the engaging Hill-Sachs E.M. Wolf Remplissage
  21. 21. www.shoulder.gr Remplissage
  22. 22. www.shoulder.gr From January 2007 to December 2010 (4 years) 48 patients Average age: 28.9 ± 7.8 years Average fu: 37.2 ± 9.9 months Recurrence percentage: 6.3%
  23. 23. www.shoulder.gr
  24. 24. www.shoulder.gr Inclusion criteria  Traumatic unidirectional anterior shoulder instability  Hill-Sachs lesion of the humeral head  Evidence of engaging Hill-Sachs lesion during dynamic evaluation under arthroscopy  Arthroscopic Bankart repair in conjunction with arthroscopic remplissage  Follow-up period longer than 2 years Exclusion criteria  Anterior glenoid rim defect or fracture exceeding 25% of the inferior glenoid diameter confirmed intra-operatively  Humeral avulsion of the glenohumeral ligaments (HAGL) detected intra-operatively  Psychological disease or epilepsy
  25. 25. www.shoulder.gr The outcome of the enhancement of the classic Bankart repair with tenodesis of the infraspinatus and posterior capsular plication is very good as far as the management of recurrent anterior shoulder instability is concerned, without significantly influencing the range of motion of the shoulder
  26. 26. www.shoulder.gr The combination of the lesions No Bone Loss Arthroscopic Bankart Repair Glenoid Bone Loss > 25% Arthroscopic Bankart Repair + Bone grafting procedure
  27. 27. www.shoulder.gr From engaging Hill Sachs to On-track & Off-track lesions No Bone Loss Arthroscopic Bankart Repair Glenoid Bone Loss > 25% Arthroscopic Bankart Repair + Bone grafting procedure What happens in between?
  28. 28. www.shoulder.gr From engaging Hill Sachs to On-track & Off-track lesions No Bone Loss Arthroscopic Bankart Repair Glenoid Bone Loss > 25% Arthroscopic Bankart Repair + Bone grafting procedure What happens in between? It is the combination of the existing lesions Large Hill-Sachs lesion + No glenoid bone loss = Small Hill-Sachs lesion + 15% -20% glenoid bone loss
  29. 29. www.shoulder.gr Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion: From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart A.Three-dimensional CT scan with en face view of a normal glenoid, with subtraction of the humeral head The width of the glenoid track without a glenoid defect is 83% of the glenoid width. B. Relation of glenohumeral joint in abduction and external rotation. The distance from the medial margin of the contact area (M) to the medial margin of the cuff footprint (F) is 83%±14% of the glenoid width: F - M = 83% of glenoid width = glenoid track.
  30. 30. www.shoulder.gr Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion: From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
  31. 31. www.shoulder.gr Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion: From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart A. 3D CT scan with en face view of a glenoid with bone loss of width d. In such a case with glenoid bone loss, the glenoid track will be 83% of the normal glenoid width minus d. B. Relation of glenohumeral joint in abduction and external rotation. One should note the loss of contact of the intact humeral articular surface with the articular surface of the glenoid. In this case the large Hill-Sachs interval (i.e., distance from posterior rotator cuff attachments to medial margin of Hill-Sachs lesion) is wider than the glenoid track, whose width has been reduced because of the glenoid bone loss.
  32. 32. www.shoulder.gr Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion: From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
  33. 33. www.shoulder.gr Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion: From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
  34. 34. www.shoulder.gr Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion: From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart How to Determine Whether Hill-Sachs Lesion Is “On Track” or “Off Track” 1. Measure the diameter (D) of the inferior glenoid, either by arthroscopy or from 3D CT scan 2. Determine the width of the anterior glenoid bone loss (d). 3. Calculate the width of the glenoid track (GT) by the following formula: GT = 0.83 D - d. 4. Calculate the width of the HSI, which is the width of the Hill-Sachs lesion (HS) plus the width of the bone bridge (BB) between the rotator cuff attachments and the lateral aspect of the Hill- Sachs lesion: HSI=HS + BB. 5. If HSI > GT, the HS is off track, or engaging. If HSI < GT, the HS is on track, or non-engaging.
  35. 35. www.shoulder.gr Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion: From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart Group Glenoid Defect Hill-Sachs Lesion Recommended Treatment 1 <25% On track Arthroscopic Bankart repair 2 <25% Off track Arthroscopic Bankart repair plus remplissage 3 >25% On track Latarjet procedure 4 >25% Off track Latarjet procedure with or without humeral sided procedure (humeral bone graft or remplissage), depending on engagement of Hill-Sachs lesion after Latarjet procedure
  36. 36. www.shoulder.gr
  37. 37. www.shoulder.gr
  38. 38. www.shoulder.gr E.Taverna, et.al,Knee Surg Sports Traumatol Arthrosc (2008) 16:872–875
  39. 39. www.shoulder.gr
  40. 40. www.shoulder.gr
  41. 41. www.shoulder.gr
  42. 42. www.shoulder.gr Arthroscopic Bone Block combined with Remplissage
  43. 43. www.shoulder.gr 3 months Post-op
  44. 44. www.shoulder.gr
  45. 45. www.shoulder.gr 3 months Post-op
  46. 46. www.shoulder.gr 3 months Post-op
  47. 47. www.shoulder.gr Our Results 15 cases Impressive early outcomes
  48. 48. www.shoulder.gr
  49. 49. www.shoulder.gr Bushnell BD, Creighton RA, Herring MM. Hybrid treatment of engaging Hill-Sachs lesions: Arthroscopic capsulolabral repair and limited posterior approach for bone-grafting. Tech Shoulder Elbow Surg 2007;8:194-203.
  50. 50. www.shoulder.gr Raiss P, Aldinger PR, Kasten P, Rickert M, Loew M. Humeral head resurfacing for fixed anterior glenohumeral dislocation. Int Orthop 2007 Dec 19 [Epub ahead of print]
  51. 51. www.shoulder.gr  The combination of bone defects is sighnificant  If the loss is mainly from the humeral head the remplissage procedure is very effective and easy to perform  If the defect is mainly in the glenoid side the Latarget procedure or an iliac crest graft combined with remplissage is very effective
  52. 52. www.shoulder.gr
  53. 53. www.shoulder.gr
  54. 54. www.shoulder.gr What is Instability  Biomechanical Dysfunction  Failure of static and dynamic stabilizers  Ranges from mild subluxation to traumatic dislocation
  55. 55. www.shoulder.gr T.U.B.S. Traumatic Unidirectional Bankart lesion Surgery A.M.B.R.I. Atraumatic Multidirectional Bilateral Rehabilitation Inferior capsular shift A.I.O.S. Acquired Instability Overstress Surgery Instability Profiles
  56. 56. www.shoulder.gr The most common presentation A patient with some degree of laxity genetically controlled dislocates his shoulder after a minor or major accident
  57. 57. www.shoulder.gr History: degree of violence Level of athletic participation number of dislocations Age of the patient Clinical examination: Generalized Joint laxity direction of aprehension dictates treatment
  58. 58. www.shoulder.gr So what makes a shoulder unstable Degree of trauma and anatomic damage Muscular dysfunction Level of athletic activity We must act in all of them
  59. 59. www.shoulder.gr Posterior instability clinical presentation in forward flexion and internal rotation sometimes after an anterior repair of a lux shoulder 2. Locked posterior dislocation with loss of external rotation 1. Sense of insecurity and feeling of instability
  60. 60. www.shoulder.gr Locked posterior dislocation is easily missed
  61. 61. www.shoulder.gr
  62. 62. www.shoulder.gr
  63. 63. www.shoulder.gr  Glenoid Index in 3D CT scan of both shoulders  Critical Limit Glenoid index 0.75 SS Burkhart Arthroscopy: Vol 24, No 4 (April), 2008: pp 376-382
  64. 64. www.shoulder.gr
  65. 65. www.shoulder.gr 23 pt active military personel, 25y mean age 20-30% bone loss 7mm of ap width 34months mean fu, 14.2% rec rate Mologne et al. AJSM 2007
  66. 66. www.shoulder.gr Parameter Pre-operatively Latest Follow-up Difference P value Active forward flexion mean value ± standard deviation 170 ± 25.8 degrees 179 ± 3.1 degrees + 9 degrees n.s. External rotation beside the body mean value ± standard deviation 73.6 ± 23.0 degrees 78.1 ± 13.1 degrees + 4.5 degrees n.s. External rotation at 90 degrees of abduction mean value ± standard deviation 89.2 ± 25.9 degrees 85.4 ± 9.3 degrees - 3.8 degrees n.s. Internal rotation median value, range T10 level (range, T6-L2) T10 level (range, T7-T12) Same level n.s. Mean ASES score mean value ± standard deviation 67.7 ± 21.5 90.8 ± 21.7 + 23.1 p<0.01 Mean Rowe-Zarins score mean value ± standard deviation 38 ± 17.3 93.8 ± 14.5 + 55.8 p<0.001 Mean Oxford Instability score mean value ± standard deviation 27.6 ± 11.1 45.1 ± 8.3 + 17.5 p<0.01
  67. 67. www.shoulder.gr
  68. 68. www.shoulder.gr Bone loss <15% (0-3.5mm) of AP width Soft tissue repair incorporating the bone fragment if possible Piasecki et al. AAOS J17 (8): 482. (2009)
  69. 69. www.shoulder.gr Sugaya et al. JBJS Am 2005

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